Blunt Aortic Injury Research Articles

One Year on: Test Your Knowledge From March 2020

1. A retrospective, observational, multicenter study evaluated aortic remodeling and associated complications in 47 patients treated with thoracic endovascular aneurysm repair (TEVAR) for blunt traumatic aortic injuries (BTAI). Which of the following is correct?1A.Aortic remodelling is more common in young patientsB.Aortic remodelling occurs mainly during the first year after TEVAR and its occurrence thereafter is rare.C.Aortic remodelling is clearly related to endograft oversizingD.There is no correlation between remodeling and associated complicationsE.None of the above

TEVAR versus open repair of blunt traumatic descending aortic injury in polytraumatic patients involved in motor vehicle accidents

BackgroundThoracic endovascular aortic repair (TEVAR) is the standard-of-care for treating traumatic aortic injury (TAI). Few retrospective studies compared TEVAR to open repair in blunt traumatic aortic injury (BTAI). Our objectives were to compare the early outcomes of TEVAR for blunt traumatic descending aortic injury to open repair (OR) in polytraumatic patients involved in motor vehicle accidents (MVA).ResultsBetween February 2005 and April 2017, 71 patients with TAI due to MVA presented to our institution. All patients with descending aortic injuries were considered for open repair (n = 41) or TEVAR (n = 30) if there was no contraindication. The primary outcome was mortality, and secondary outcomes were stroke, paraplegia, intensive care unit (ICU), and hospital stay.The mean age was 28.4 ± 10.1 years in the OR group and 33.3 ± 16.6 years in TEVAR-group (P = 0.13). The injury severity scores were 41 ± 10 in the OR group and 33 ± 17 in the TEVAR group (P = 0.03). Patients in the OR group underwent emergency repair with a mean time of 0.56 ± 0.18 days from arrival. The TEVAR group had a longer time interval between arrival and procedure (2.1 ± 1.7 days, P = 0.001). The OR group had more blood transfusion (24 (58.5%) vs. 8 (27.5%), P = 0.002), renal impairment (6 (14.6%) vs. 1 (5.50%), P = 0.23), and wound infection (21 (51.2%) vs. 3 (10%), P < 0.001). Three TEVAR patients had a perioperative stroke compared to two patients in the OR group (P = 0.64). There was no difference in the mean ICU (6 ± 8.9 vs. 5.3 ± 2.9 days; P = 0.1) or hospital stay (20.1 ± 12.3 vs. 20.1 ± 18.3, P = 0.62) between the two groups. There were four deaths in the OR group and none in the TEVAR group (P = 0.13).ConclusionThe results of TEVAR were comparable with the open repair for traumatic aortic injury with good early postoperative outcomes. TEVAR repair could be associated with lower mortality, blood transfusion, and infective complications. However, the complexity of the injury and technical challenges were higher in the open group.

Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution.

Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8±13.6years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n=75, 48.7%), acute type B aortic dissections (n=46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n=28, 18.2%), and blunt traumatic aortic injuries (n=5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0-1-2 (n=75, 48.7%), zone 3 (n=66, 42.9%) and zone 4 (n=13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.

Efficacy and Safety of Heparinization before Deployment of Endograft for Blunt Traumatic Aortic Injury in Severely Injured Patients

The administration of unfractionated heparin (UFH) during endovascular repair of blunt traumatic aortic injury (BTAI) is controversial. The aim of the study is to report the early outcomes of patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI, and to assess the individualized intraoperative use and dose of UFH. This is a retrospective analysis including consecutive patients treated with TEVAR for BTAI of the descending aorta between January 1st, 2005 and December 31st, 2018. Intraoperative use and doses of UFH were analyzed. Primary outcome included a reintervention because of new onset bleeding and/or thromboembolic complication and 30-day mortality. Technical success, injury severity score (ISS), timing of treatment, and neurologic deterioration were secondary outcome. Thirty-six patients with a mean age of 47 ± 18 years, 30 males (83%), were included. Intraoperative administration of UFH was recorded in 30/36 patients (83%) with a mean dose of 4750 ± 2180 IU. Two patients had no UFH because of extensive intracranial hemorrhage or suspected relevant liver laceration, respectively; 1 died in theatre, 1 was already anticoagulated having a mechanical aortic valve, and in 2 no information about heparin use was found. During 30 days of follow-up, 3 patients died (8%; 3/36): 1 patient with completely transected aorta died on-table and 2 on the fifth postoperative day, 1 from trauma-associated brain injury and 1 with multi organ failure. No bleeding or thromboembolic complication requiring reintervention occurred in any patient during 30 days follow-up. In 3 patients partial unintentional coverage of the left common carotid artery occurred, resulting in technical success of 89% (32/36). Mean ISS was 43 ± 15. Thirty-five patients (97%) were severely injured having an ISS ≥ 25. Twenty-nine patients (81%) were treated within 24 hr and 6 patients (17%) within 1 week. No stroke or spinal cord ischemia was observed. Systemic heparinization in different doses during TEVAR for BTAI can be safe with no intraoperative bleeding or thromboembolic complications in early postoperative period.

Reevaluating the Need for Routine Coverage of the Left Subclavian Artery in Thoracic Blunt Aortic Injury

Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic blunt aortic injury (TBAI). A 20mm proximal seal zone is recommended based on aneurysmal disease literature which often results in coverage of the left subclavian artery (LSA). The aim of this study was to analyze our experience with TEVAR for TBAI and evaluate whether 20mm is required to achieve successful remodeling. This is a single-center, retrospective study of all consecutive patients who received a TEVAR for treatment of moderate and severe TBAI between April 2014 and November 2018. Three-dimensional software reconstruction was used for computed tomography (CT) scan centerline measurements. Outcomes included technical success, need for reinterventions, and immediate and long-term aortic-related complications. Sixty-one patients underwent TEVAR for TBAI during the study period. Twenty-eight (46%) patients underwent LSA coverage with an average distance from the LSA to the injury of 6.4mm (0-15.1mm). Of the 33 (54%) patients who did not undergo coverage of the LSA, 22 patients (66%) had less than 20mm of proximal seal zone. The mean distance from the LSA to injury in this group was 16.6mm (7.9-29.5mm). None of the patients with LSA coverage developed ischemic symptoms, and an average decrease in left arm systolic blood pressure of 24.8mm Hg (0-62mm Hg) was noted versus the right arm. There was no aortic-related mortality in either group. Follow-up CT scans revealed excellent remodeling. Immediate outcomes of TEVAR for TBAI with LSA coverage are well tolerated; however, the long-term sequela of LSA coverage is unknown. Exclusion of the injury and excellent remodeling appear to occur with less than 20mm of proximal seal, and perhaps more attention should be made to preservation of the LSA.

Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury

Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset. Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients. 17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p= 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001). TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.

Intraoperative heparin use is associated with reduced mortality without increasing hemorrhagic complications after thoracic endovascular aortic repair for blunt aortic injury

ObjectiveThoracic endovascular aortic repair (TEVAR) is an effective treatment of blunt thoracic aortic injury (BTAI). However, the risks and benefits of administering intraoperative heparin in trauma patients are not well-defined, especially with regard to bleeding complications. MethodsThe Vascular Quality Initiative registry was queried from 2013 to 2019 to identify patients who had undergone TEVAR for BTAI with or without the administration of intraoperative heparin. Univariate analyses were performed with the Student t test, Fisher exact test, or χ2 test, as appropriate. Multivariable logistic regression was then performed to assess the association of heparin with inpatient mortality. ResultsA total of 655 patients were included, of whom most had presented with grade III (53.3%) or IV (20%) BTAI. Patients receiving heparin were less likely to have an injury severity score (ISS) of ≥15 (70.2% vs 90.5%; P < .0001) or major head or neck injury (39.6% vs 62.9%; P < .0001). Patients receiving heparin also had a lower incidence of inpatient death (5.1% vs 12.9%; P < .01). Across all injury grades, heparin use was not associated with the need for intraoperative transfusion or postoperative transfusion or the development of hematoma. In patients with grade III BTAI, the nonuse of heparin was associated with an increased risk of lower extremity embolization events (7.4% vs 1.8%; P < .05). On multivariable logistic regression analysis for inpatient mortality, intraoperative heparin use (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11-0.86; P < .05) and female gender (OR, 0.11; 95% CI, 0.11-0.86; P < .05) were associated with better survival, even after controlling for head and neck trauma and injury grade. In contrast, increased age (OR, 1.06; 95% CI, 1.03-1.1; P < .001), postoperative transfusion (OR, 1.06; 95% CI, 1.02-1.11; P < .01), higher ISS (OR, 1.04; 95% CI, 1.01-1.07; P < .05), postoperative dysrhythmia (OR, 4.48; 95% CI, 1.10-18.18; P < .05), and postoperative stroke or transient ischemic attack (OR, 5.54; 95% CI, 1.11-27.67; P < .05) were associated with increased odds of inpatient mortality. ConclusionsIntraoperative heparin use was associated with reduced inpatient mortality for patients undergoing TEVAR for BTAI, including those with major head or neck trauma and high ISSs. Heparin use did not increase the risk of hemorrhagic complications across all injury grades. Also, in patients with grade III BTAI, heparin use was associated with a reduced risk of lower extremity embolic events. Heparin appears to be safe during TEVAR for BTAI and should be administered when no specific contraindication exists.

Thoracic Trauma

More than 85% of blunt and penetrating trauma to the thorax results in injury to the lungs or ribs. Among civilians, blunt trauma is the most common mechanism, while penetrating trauma is the most common among military sectors. This review describes the assessment and stabilization, diagnosis, treatment and disposition, and outcomes of thoracic trauma. Videos shows the “lung point” sign on M-mode and two-dimensional ultrasonography, and a transthoracic echocardiogram clip of pericardial clot and tamponade due to a gunshot wound. Figures show a sonogram showing the “lung point sign”, a chest x-ray and computed tomographic scan demonstrating right-sided hemothorax in a patient with a right chest stab wound, and a three-dimensional computed tomographic scan and chest x-ray of a blunt trauma patient with displaced fractures of the left lateral sixth to ninth ribs. Tables list types of injuries, NEXUS chest decision instrument imaging criteria, level 2 evidence-based recommendations for the management of pulmonary contusion and flail chest by the Eastern Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma practice guidelines for managing issues with pulmonary contusion and flail chest, and the Vancouver simplified and University of Washington grading systems for blunt aortic injury. This review contains 2 videos, 4 highly rendered figures, 10 tables, and 94 references.

Blunt abdominal aortic injury in children associated with lap belts.

Blunt abdominal aortic injury in children associated with lap belts.

Minimal Aortic Injury: Mechanisms, Imaging Manifestations, Natural History, and Management.

Over the last 2 decades, increased depiction of minimal aortic injury (MAI) in the evaluation of patients who have sustained trauma has mirrored the increased utilization and improved resolution of multidetector CT. MAI represents a mild form of blunt traumatic aortic injury (BTAI) that usually resolves or stabilizes with pharmacologic management. The traditional imaging manifestation of MAI is a subcentimeter round, triangular, or linear aortic filling defect attached to an aortic wall, representing a small intimal flap or thrombus consistent with grade I injury according to the Society for Vascular Surgery (SVS). Small intramural hematoma (SVS grade II injury) without external aortic contour deformity is included in the MAI spectrum in several BTAI classifications on the basis of its favorable outcome. Although higher SVS grades of injury generally call for endovascular repair, there is growing literature supporting conservative management for small pseudoaneurysms (SVS grade III) and large intimal flaps (>1 cm, unclassified by the SVS), hinting toward possible future inclusion of these entities in the MAI spectrum. Injury progression of MAI is rare, with endovascular aortic repair reserved for these patients as well as patients for whom medical treatment cannot be implemented. No consensus on the predetermined frequency and duration of multidetector CT follow-up exists, but it is common practice to perform a repeat CT examination shortly after the initial diagnosis. The authors review the evolving definition, pathophysiology, and natural history of MAI, present the primary and secondary imaging findings and diagnostic pitfalls, and discuss the current management options for MAI. Online DICOM image stacks are available for this article. ©RSNA, 2020.

Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations.

Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI. Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases. TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.

Man with trauma following motorcycle crash.

A 56-year-old male presented to the emergency department (ED) following a frontal impact motorcycle accident. The patient was pale with persistent hypotension, tachypnea, and tachycardia along with bilateral lower limbs paralysis and a complete loss of sphincter functions. Patient was intubated, and transesophageal echocardiography performed by attending emergency physician at ED critical care bayshowed the transverse and longitudinal view of the descending aorta with hypoechoic, well-defined, crescent-shaped thickening of anterior aortic wall suggestive of intramural hematoma (Figures 1, 2; Supporting Information Videos S1 and S2). Computed tomography (CT) showed fracture T11 vertebra, intramural hematoma, and peri-aortic hematoma along the arch of the aorta extending down to upper abdominal aorta at the level of T12 (Figure 3). Traumatic thoracolumbar spine fracture with a concomitant blunt aortic injury is uncommon (1.4%) but potentially fatal.1 Most fractures associated with blunt traumatic aortic injury occurred at the level of T11–L2 vertebra (62%).1 ED transesophageal echocardiography is a potential new imaging adjunct in resuscitation.2-4 Even though the surface ultrasound has become an important bedside imaging tool in initial management of trauma patients in ED, its limitations include poor evaluation of vascular pathologies (ie, BTAI).5 The role of ED transesophageal echocardiography for the early detection of BTAI in hemodynamically unstable trauma patient was reported by Osman et al.6 The patient was managed conservatively and was discharged from spinal intensive care unit after day 10. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Utility of Single-Branched Thoracic Endograft in Patients Requiring Zone 2 Seal During Thoracic Endovascular Aortic Repair

Single-branched thoracic endografts (SBTEs) are under investigation for treatment of thoracic aortic disease that requires zone 2 seal during thoracic endovascular aortic repair (TEVAR). A variety of anatomic criteria must be met for their effective implantation. Our aim was to analyze anatomic suitability for SBTE. We performed a retrospective review of 103 TEVAR procedures in 88 patients at our academic referral center between 2017 and 2019. Proximal seal was achieved in zone 3 or zone 4 (n = 37 [36%]), zone 2 (n = 30 [29%]), or zone 0 or zone 1 (n = 36 [35%]). We analyzed the zone 2 group’s operative angiograms and preoperative computed tomography angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery, left subclavian artery (LSA), and proximal extent of aortic disease to determine whether patients met anatomic criteria using the instructions for use (IFU) of the Navion Mona LSA (Medtronic, Santa Rosa, Calif; Table I). Average age in the zone 2 group was 64 years (range, 26-85 years); 17 were male (57%). Indications (Table II) were acute type B dissection (ATBD; n = 13 [43%]), aneurysm (n = 15 [50%]), and blunt aortic injury (n = 2 [7%]). The LSA was revascularized in 20 (67%): carotid subclavian bypass or transposition, n = 17; laser fenestration, n = 3. Overall, 14 (47%) of the zone 2 patients met the IFU. Reasons for failure are listed in Table I. Of the 16 who did not meet IFU, 9 had multiple exclusion criteria. Inadequate aortic diameter excluded only the two blunt aortic injury patients. The proportion of patients who met IFU criteria by indication are listed in Table II. Fewer ATBDs (5/13 [38%]) met IFU than aneurysms (9/15 [60%]), but this was not statistically significant (P = .26). Of the eight ATBD patients who failed to meet criteria, seven had dissection at or into the origin of the LSA. If dissection into the LSA origin was allowed in ATBD, three of the seven would have otherwise qualified. Approximately half of patients who require TEVAR seal in zone 2 meet criteria for this SBTE. The device may offer the ability to provide flow to the LSA without the need for adjuvant revascularization procedures. Patients with aneurysms more often met the IFU than those with acute dissection. A modification to the IFU to allow dissection up to the LSA origin would increase eligibility in ATBD by >50%. Clinical efficacy data, however, are needed to determine whether this would be effective.Table IAnatomic criteria for the Navion Mona LSAAnatomic criteriaCriteria to meet IFUMean ± SD, mmNo. (%) failing to meet criteriaAortic diameter at proximal seal zoneDissection: 28-44 mm Aneurysm/PAU: 25-42 mm30.2 ± 3.82 (7)LSA diameter8-13 mm9.47 ± 1.30 (0)Distance between orifices of LCCA to LSA≥10 mm10.9 ± 6.012 (40)Distance of LCCA to aortic disease≥20 mm22.1 ± 10.111 (37)Distance of LSA to aortic disease≥0 mm (presence of nondiseased aorta distal to LSA)5.6 ± 6.311 (37)IFU, Instructions for use; LCCA, left common carotid artery; LSA, left subclavian artery; PAU, penetrating aortic ulcer; SD, standard deviation. Open table in a new tab Table IIThoracic endovascular aortic repair (TEVAR) indications and proportion that met the instructions for use (IFU)IndicationNo.No. (%) meeting criteriaAcute type B dissection135 (38)Aneurysm or penetrating ulcer96 (67)Aneurysm in chronic dissection63 (50)Blunt aortic injury20 (0) Open table in a new tab

Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department.

Although surface sonography has become an essential diagnostic tool in the evaluation of trauma patients, important limitations of this modality include the evaluation of retroperitoneal hemorrhage and mediastinal pathology, such as blunt traumatic aortic injuries (BTAI). As in other emergency applications where surface sonography can't provide the information needed, focused transesophageal echocardiography (TEE) may represent a valuable diagnostic tool in the evaluation of hemodynamically unstable trauma patients with suspected thoracic pathology such as BTAI. We present a series of five cases that illustrate the diagnostic value of emergency physician-performed resuscitative TEE in the diagnosis of BTAI in patients presenting with blunt thoracic trauma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As the use of point-of-care TEE during resuscitation continues to expand in emergency medicine, the evaluation of patients with BTAI represents a novel application where this emerging modality can allow early diagnosis of these injuries in hemodynamically unstable patients.

Intraoperative Heparin Use Is Associated With Reduced Inpatient Mortality After Thoracic Endovascular Aortic Repair for Blunt Aortic Injury

Thoracic endovascular aortic repair (TEVAR) is an effective treatment for blunt thoracic aortic injury (BTAI), but the risks and benefits of administering intraoperative heparin in trauma patients are not well defined.

Re-evaluating The Need for Routine Coverage Of The Left Subclavian Artery In Thoracic Blunt Aortic Injury

Thoracic Endovascular Aortic Repair (TEVAR) is the treatment of choice for thoracic blunt aortic injury (TBAI) with a 20mm proximal seal zone recommended based on aneurysmal disease literature, often requiring coverage of the left subclavian artery (LSA). The aim of this study was to analyze our experience with TEVAR for TBAI and evaluate whether 20mm is required to achieve successful remodeling.

Blunt Aortic / Inferior Vena Cava Injury: Are We Consistently Providing the Same Level of Care?

Major vascular traumatic injuries have a higher pre-hospital and in-hospital mortality rate. The different mechanisms of injury and anatomy of the aorta and inferior vena cava (IVC) make the management a constant challenge to surgeons and clinicians. Blunt traumatic aortic injury (BTAI) can occur at the thoracic or abdominal level, each of which possesses different considerations. Blunt traumatic inferior vena cava injury (BTIVCI) also has important diagnostic challenges since the lesion may not be as evident in the IVC as compared to the aorta, possibly due to lower caval pressures or the ability to self-tamponade from adjacent structures. Endovascular management has significantly increased in the past years, and despite an improvement in mortality, the approach to aortic and IVC injuries is not well standardized. Diagnostic imaging helps to classify the extent of the lesions and guide towards the best therapeutic options for each case. Conservative management, in some cases, has shown to reduce mortality, and close follow-up has proven good outcomes. Future research will provide more evidence to determine the best approach to BTAI and BTIVCI for better long-term outcomes. This article aims to provide an updated review of the current literature regarding diagnosis, classification, and management of BTAI and BTIVCI.

Five-Year Outcomes From the United States Pivotal Trial of Valiant Captivia Stent Graft for Blunt Aortic Injury

The Clinical PeRformancE of the Valiant Thoracic Stent Graft with Capitvia Delivery System for the EndovaSCUlar treatment of Blunt Thoracic Aortic Injuries (RESCUE) study evaluating thoracic endovascular repair using the Valiant Captivia endograft for blunt thoracic aortic injury reported promising 30-day outcomes. We now describe 5 years of follow-up of this cohort. Fifty patients (mean age 40.7 ± 17.4 years, 76% male, mean injury severity score 38 ± 14.4) were treated for blunt thoracic aortic injury (2010 to 2012) with this endograft. Seventy percent (n= 35) of blunt thoracic aortic injury extent was grade III or higher. Extent of arch repair required full (40%) or partial (18%) left subclavian artery coverage. At 5 years, clinical and imaging compliance was 90.3% (28 of 31) and 67.7% (21 of 31), respectively. Thirty-day mortality was 8%. Three additional patients died of non-device-related causes (respiratory failure, infection, metastatic cancer) through 5-year follow-up, yielding a Kaplan-Meier survival of 85.2% through 5 years. Neither stroke nor spinal cord ischemia was observed at 5 years. Two type II endoleaks seen at 30 days resolved spontaneously, and no additional endoleaks were described in the study cohort through 5 years. No secondary endovascular procedures or conversion to open surgery were reported through 5 years. Four subjects underwent left subclavian revascularization for symptomatic indications. Finally, complete exclusion of the traumatic injury was maintained with no incidences of stent graft kinking, fracture, loss of patency, or migration through 5 years in all patients. This multicenter clinical trial describes excellent 5-year outcomes and durable exclusion of blunt thoracic aortic injury using a novel stent graft system. Thoracic endovascular repair with this endograft appears to be a safe and effective treatment option for patients with blunt thoracic aortic injury.

Eleven-Year Experience Treating Blunt Thoracic Aortic Injury at a Tertiary Referral Center

Blunt thoracic aortic injury treatment has evolved over the past decade particularly with respect to endovascular intervention options. We investigated the trends in blunt thoracic aortic injury management and outcomes over an 11-year span at the sole tertiary referral center in our state. We retrospectively reviewed all patients who presented to our institution with blunt traumatic aortic injury between 2007 and 2017. Baseline demographics including aortic injury grade, injury severity score, and abbreviated injury scale were collected. Outcomes were compared by type and timing of treatment, which included either nonoperative management, endovascular repair, or open surgical repair. Bivariate and multivariable analyses were performed to examine treatment group differences and factors associated with 30-day mortality. In total, 229 patients were reviewed. The distribution of injury severity was grade 1 (30%), grade 2(8%), grade 3 (30%), and grade 4 (31%). Overall, 27% of patients underwent endovascular repair, 29% open surgery, and 44% definitive nonoperative management. Over the study period, there was a dramatic decline in open surgery and a corresponding rise in endovascular treatment. Thirty-day mortality for the entire cohort was 22%. Mortality by treatment subgroup was 30% for nonoperative management, 8.2% for endovascular treatment, and 21% for open surgery. Delaying endovascular or open surgical treatment by at least 24 hours after admission was associated with significantly improved 30-day survival. Procedural intervention, whether endovascular or surgical, is associated with improved mortality compared with nonoperative treatment. Delayed intervention, particularly in the case of high-grade injuries, may allow for initial patient stabilization and improved outcomes.

Emergency percutaneous thoracic endovascular aortic repair for patients with traumatic thoracic aortic blunt injury: A single center experience

PurposeTo analyze the efficacy and outcome of percutaneous thoracic endovascular aortic repair (TEVAR) in patients with traumatic blunt aortic injury in our single-center. MethodsFrom January 2014 to December 2018, a total of 89 patients with traumatic blunt aortic injuries were treated with emergency TEVAR in our center. Their clinical data such as demographics, operative details and postprocedure outcomes were analyzed retrospectively in this study using SPSS 20 software. Continuous variables were expressed as mean and standard deviation or median and interquartile range. Categorical variables are expressed as the numbers and percentages of patients. ResultsThe median age of the patients was 37 years, and 76 (85.4%) were males. All the patients were involved in violent accidents and combined with associated injuries. Two patients died while awaiting the operations and 87 patients underwent emergency percutaneous TEVAR, with a 100% technique success. The mean time interval from admission to operating room was (90.1 ± 18.7) min, and the mean procedure time was (54.6 ± 11.9) min. Eighty (92.0%) patients were operated on under local anesthesia, while other 7 (8.0%) patients were under general anesthesia. Two cases underwent open repair of the femoral arteries because of the pseudoaneurysm formation of the access vessels. A total of 98 aortic covered stent grafts were deployed, of which 11 patients used two stent grafts (all in dissection cases). The length of the stent was (177.5 ± 24.6) mm. The horizontal diameter of aorta arch at the proximal left subclavian artery ostium was (24.9 ± 2.4) mm, the proximal diameter of the covered stent was (30.5 ± 2.6) mm, and the oversize rate of proximal site was (22.7 ± 4.0)%. The proximal landing zone length was (14.1 ± 5.5) mm. The left subclavian artery ostium was completely covered in 5 patients and partially covered in 32 patients. No blood flow reconstruction was performed. The overall aortic-related mortality was 2.25% (2/89). Among 87 patients, the median follow-up time was 24 months. Postoperative computed tomography angiography scans demonstrated no residual pseudoaneurysm, hematoma or endoleak. One patient complained of mild left upper limb weakness during follow-up due to left subclavian artery occlusion. Neither late death, nor neurological or other complications occurred. ConclusionEmergency percutaneous endovascular repair is a less invasive and effective approach for the treatment of traumatic blunt aortic injuries. Long-term results remain to be further followed.